After tragedy, Duke works to improve patient safety

The Centers for Medicare & Medicaid Services (CMS) has accepted a corrective action plan from Duke University Hospital in Durham, NC, to ensure safety in the hospital’s intensive care nursery (ICN). CMS directed Duke to make patient safety changes following an Aug. 31 incident in which a premature infant suffered burns from heated air in an incubator.

The incident followed two other reported cases at the hospital involving children recently, including a heart/lung transplant case in February and an accidental flash fire in the pediatric intensive care unit in June that resulted in burns to a child.

Duke and CMS have agreed that Duke University Hospital will make significant changes that strengthen the hospital’s patient safety programs, particularly in pediatric care. For starters, Duke officials said the hospital is establishing a pediatric safety program.

The Duke University Health System (DUHS) also will take several steps that increase safety protections, such as inviting outside experts to serve on its Patient Safety and Quality Assurance Committee. CMS administrator Tom Scully recently announced that Duke’s corrective actions helped it avoid a longer bureaucratic process.

"Traditionally, CMS would be issuing notices proposing to revoke Duke’s hospital certification, Duke would appeal, and a long, cumbersome process would begin," he said. "Instead, we have avoided that normal bureaucratic dance and engaged in a real workout plan with Duke. This will more quickly improve patient safety — and result in real change at Duke Hospital — which is what this is all about."

CMS initiated a review involving Duke University Hospital on Sept. 4, 2003, after the hospital self-reported an incident in which a premature infant received a burn from heated air in an incubator in its ICN. The infant is no longer at Duke and has a favorable prognosis, Duke officials report.

Following its review, CMS informed hospital officials on Sept. 19 that it would terminate its eligibility for Medicare and Medicaid reimbursement unless Duke University Hospital addressed issues the agency had identified. CMS’ review identified several problems in the infant’s treatment: Nursing staff were inadequately trained in the proper use of the incubator; the infant was not properly monitored during the crucial time period after the procedure was done; and staff failed to note that sterile covers had fallen over one of the incubator’s warm air outlet vents, which channeled the heated air directly onto the infant’s right side and caused the burns.

Duke’s corrective plan includes the following corrective actions: reviewing and revising various ICN policies such as the monitoring of patients, vital signs monitoring, thermoregulation and documentation guidelines; educating ICN staff on these revised policies prior to their next shift assignment; and re-educating ICN staff on the safe use of incubators, insertion of umbilical artery catheters and endotracheal tubes, and role delineation of ICN staff.

Additionally, Duke will strengthen policies and guidelines on where procedures may be performed in the ICN, actions to be taken should a procedure need to be performed in an incubator in the ICN, insertion of umbilical artery catheters and endotracheal tubes, actions to be taken should a portable X-ray not be performed within the expected time frame, and delineation of the roles of the care nurse and neonatal nurse practitioner while performing a procedure in the ICN. Finally, the ICN will have temperature alarms on monitors used in the unit defaulted to the "on" position.